Professional Documents
Culture Documents
LA SALLE
COLLEGE OF MEDICINE
PHYSICAL DIAGNOSIS
SCHOOL YEAR 2017-2018
PART I: (History part…subjective data. Please omit the word PART I, PART II etc in your actual paper)
GENERAL DATA:
Name, age, gender, marital status, nationality, religion, occupation, address, number of admission/s, date
and time of admission
CHIEF COMPLAINT: (px’s symptom that prompted admission. Must be short, concise and direct to the
point)
OB-GYNE HISTORY:
Menarche
Menstrual period: duration, flow, cycle length
OB Score: G1P1 (T-P-A-L)
FAMILY HISTORY:
PERSONAL SOCIAL HISTORY: (include smoking and alcoholic beverage drinking history here.)
PART II:
GENERAL SURVEY:
Ex. Patient is awake, conscious, coherent, bed-bound, not in cardiorespiratory distress
SKIN:
HEENT:
NECK:
THORAX AND LUNGS: (same format for the succeeding organ systems)
Inspection
Palpation
Percussion
Auscultation
BREAST AXILLAE:
CARDIOVASCULAR SYSTEM:
ABDOMEN:
EXTREMITIES:
RECTAL/GENITAL EXAM:
NEUROLOGIC EXAM:
PART III:
DIFFERENTIAL DIAGNOSIS (at least 3)
WORKING DIAGNOSIS
BASES FOR THE DIAGNOSIS
From the history
From PE
PART IV:
PLANS:
Diagnostic
Therapeutic
Non-pharmacologic
Example:
GENERAL DATA:
A.B., 56-year old, female, married, Filipino, Roman Catholic, housewife, of Barangay 1, Bacolod City, was
admitted for the 1st time at CLMMRH on June 12, 2012 at 12:30pm.